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Virginia Henderson International Nursing e-Repository > Sigma Theta Tau International (STTI) > STTI Biennial Convention > Implementation of Evidence-Based Practice for Mechanically Ventilated Adults

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Type: Presentation
Title: Implementation of Evidence-Based Practice for Mechanically Ventilated Adults
Implementation of Evidence-Based Practice for Mechanically Ventilated Adults
Conference Sponsor:Sigma Theta Tau International
Conference Year:2005
Author:Hardin-Pierce, Melanie G., RN, MSN, ACNP
P.I. Institution Name:University of Kentucky
Title:Assistant Professor
Practice Problem and Synthesis of the Evidence: Mechanically ventilated patients are at an increased risk for ventilator-dependent pneumonia (VAP). Prolonged time spent on mechanical ventilation due to the incidence of adverse events increase morbidity, mortality, and the risk for and incidence of VAP. There is a lack of guidelines incorporating evidence-based practice into the care of mechanically ventilated patients. The lack of evidence-based guidelines result in non-standardized care, and increases risk for VAP, prolongs length of stay, and the time patients spend on mechanical ventilation. Evidence suggests that specific nursing and physician driven interventions, when ?bundled? together, lead to improved outcomes in mechanically ventilated patients, including decreased incidence of VAP. The purpose of this project is to implement a nursing and physician-driven, economically feasible, and quantifiable ?bundle? of interventions to improve outcomes in mechanically ventilated patients. The interventions will include implementation of the following guidelines: Deep Vein Thrombosis (DVT) Prophylaxis, Peptic Ulcer Disease (PUD) Prophylaxis, Sedation Protocol with daily interruption, Oral Care, and Elevation of the Head of the Bed (HOB). The University of Kentucky Internal Review Board approved this study for Research Integrity. Type of Evidence Used and Synthesized to Implement and Evaluate the Program: The best available published evidence related to the incidence and prevention of adverse events in the adult mechanically ventilated patient population was used to develop guidelines/protocols to decrease the risk of adverse events, and the number of ventilator days. Adverse events targeted by this program are DVT, PUD, VAP, and prolonged ventilator weaning from inappropriate sedation. The specific types of evidence used to develop the program interventions include published experimental and non-experimental studies, systematic reviews, national guidelines, national benchmark data, and local secondary hospital data. Both process and outcome program evaluation involved the use of self-report survey, chart audit, observation, and hospital secondary data for quality control. Planned Strategy for Improvement: The Focus, Development, Development, and Evaluation (FADE) process was used to implement the program. A systematic program analysis and needs assessment was conducted prior to program implementation relative to the practice problem. Barriers to implementation were identified and considered when developing the implementation plan. Relevant principles from Titler (2001) model were employed in the development, implementation, and evaluation of the ventilator bundle program. Program Implementation: ? Systematic review of the current best evidence ? Program analysis including determination of total cost and savings opportunities ? Development of a Multi-disciplinary Evidence-Based Practice group to facilitate implementation and provide expertise to guide practice and policy change ? Consensus building among stakeholders for policy change ? Development of policy and guidelines ? Funding acquisition to cover purchase of oral care products ? Development of documentation methods/forms ? Development of process and outcome evaluation plan ? Phased implementation including education interventions ? Process monitoring via audits, direct observation and survey ? Outcome evaluation for VAP, ventilator days, intensive care unit (ICU) length of stay utilizing hospital secondary data Method of Evaluation: 1) Process ? Process monitor survey of staff ? Compliance audits via chart reviews for documentation ? Observation via rounds by an advanced practice nurse to audit HOB elevation, oral care product use, sedation interruption 2) Outcome ? Indicators measured include average ICU length of stay, average ventilator days, incidence of VAP utilizing hospital secondary data source ? Cost of program/ average cost savings Outcomes and Results: ? Approval of a new infection control position to measure device related infections including VAP ? Implementation of a new policy stating that the frequency of in-line suction catheter changes be done only for visible soiling or malfunction; and that the frequency of ventilator circuitry changes be done on admission only resulting in cost savings ? Inability to reliably measure incidence of VAP due to lack of Infection Control Department resources and delays in implementing a new measurement process 1) Process evaluation consisted of measuring compliance to the ?ventilator bundle? interventions through documentation via chart audits for the first quarter after program implementation. Compliance results were: ? Oral care ? 86% ? PUD prophylaxis ? 99% ? DVT prophylaxis ? 97% ? HOB elevation ?79% ? Sedation interruption ? 40% 2) Outcomes at six months: ? Mortality decreased from 22% to 19% ? Antibiotic use decreased by 54% ? Average ventilator days decreased from 6.76 to 4.86 resulting in an average cost savings of $5,868 per patient ? Average ICU length of stay decreased from 6.72 to 6.23 Lessons Learned: ? Have a fully functioning individual and process in place to measure and benchmark VAP rates prior to program implementation ? Pilot in one unit only ? Implement each component separately instead of all at once ? Use separate order form for sedation awakening, and include a protocol for daily neuromuscular blockade interruption ? Incorporate the sedation interruption criteria and assessment with the established ?Pain Assessment Form? ? Determine the acceptable variance for oral care compliance, and determine potential reasons for non-compliance to oral care policy, and track them Actions Based on Program Evaluation: ? Re-educate physician and nursing staff on the sedation interruption intervention and the use of the Riker Scale to measure level of sedation ? Pilot of the re-education intervention and implementation of the sedation interruption assessment and protocol in the Medicine Intensive Care Unit
Repository Posting Date: 26-Oct-2011
Date of Publication: 17-Oct-2011
Sponsors: Sigma Theta Tau International
Appears in Collections: STTI Biennial Convention

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